Patient satisfaction after lower limb replantation surgery for traumatic amputation - a qualitative study.

BACKGROUND: The majority of published literature clinically assesses surgical outcomes after lower limb replantation for traumatic amputations. However, patients' satisfaction and quality of life may not be accurately measured through rigid scoring using standardized patient reported outcome measures. PURPOSE: The aim of this study was to qualitatively assess patient satisfaction and factors associated with achieving good outcomes after successful lower limb replantation surgery. METHODS: A semi-structured interview was conducted with 12 patients who underwent lower limb replantation surgery following traumatic amputation injuries. The interview focused on the patients' experience and satisfaction throughout their injury, surgical journey, rehabilitation and reintegration into their communities. An inductive and deductive thematic analysis was applied using the recorded transcripts to evaluate the overall satisfaction of the patients after lower limb replantation surgery. RESULTS: The following observations emerged from the structured themes among all the patients interviewed: (1) Family and social support was significantly associated with improved qualities of life and satisfaction after lower limb replantation; (2) Patients were generally satisfied with their outcomes despite limitations in physical capabilities; (3) Satisfaction was associated with acceptance of their cosmetic deformity; (4) Social integration and being able to participate in a meaningful manner was associated with greater satisfaction after recovery. CONCLUSIONS: Patients who undergo lower limb replantation can have a significantly improved quality of life if they have strong social support, are able to contribute in a meaningful manner to their communities after surgery, and are accepting of their cosmetic deficiencies.

Return to Driving Is Safe 6 Weeks After Anterior Cervical Surgery for Symptomatic Cervical Degenerative Disc Disease.

STUDY DESIGN: Prospective Cohort Study. OBJECTIVES: This study aims to determine the timing and clinical parameters for a safe return to driving. SUMMARY OF BACKGROUND DATE: Returning to driving after cervical spine surgery remains a controversial topic, with no clear consensus on how to best assess a patient's fitness to drive. Previous studies using brake reaction time or subjective questionnaires recommend a return to driving 6 weeks after surgery. METHODS: Patients above 18 years of age who underwent anterior cervical spine surgery for symptomatic cervical degenerative disk disease and possessed a valid motorcar driving license were recruited from 2018 to 2020. Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA) scores, range of motion, and functional strength of the cervical spine were collected preoperatively and at 2-, 4-, 6- and 12 weeks postsurgery. Patients underwent a standard functional driving assessment protocol at the institution to determine their fitness to drive. This comprised of a clinic-based off-road screening tests and on-road driving test in a real-world environment. RESULTS: Twenty-one patients were recruited. The mean age was 56.6±8.9 years. Eighty-one percent of the patients passed the on-road driving assessment at 6 weeks. Patients who passed the driving assessment had lower mean NDI scores, 3.4±3.1 versus 10.8±8.0 ( P =0.006), and higher mean mJOA scores 16.1±0.6 versus 15.0±1.8 ( P =0.045). Patients who passed the driving assessment also had higher functional cervical flexor strength, 21.1s±5.8s versus 13.0s±10.2s ( P =0.042) in a supine position but not correlated with a range of motion of the spine in all directions. CONCLUSION: Most patients undergoing single or dual-level anterior cervical surgery for symptomatic cervical degenerative disk disease demonstrate the ability to pass a standardized driving assessment and are safe to return to driving more than 6 weeks after surgery. Driving ability appears to be correlated with NDI scores ≤3 ( P =0.006), mJOA scores ≥16 ( P =0.045), and cervical flexion endurance of ≥21s ( P =0.042). LEVEL OF EVIDENCE: Level II.

Enhanced Recovery after Surgery for Knee Arthroplasty in the Era of COVID-19.

Enhanced recovery after surgery (ERAS) represents a paradigm shift in perioperative care, aimed at achieving early recovery for surgical patients, reducing length of hospital stay, and complications. The purpose of this study was to provide an insight of the impact of the COVID-19 on ERAS protocols for knee arthroplasty patients in a tertiary hospital and potential strategy changes for postpandemic practice. We retrospectively reviewed all cases that underwent surgery utilizing ERAS protocols in the quarter prior to the pandemic (fourth quarter of 2019) and during the first quarter of 2020 when the pandemic started. A review of the literature on ERAS protocols for knee arthroplasty during the COVID-19 pandemic was also performed and discussed. A total of 199 knee arthroplasties were performed in fourth quarter of 2019 as compared with 76 in the first quarter of 2020 during the COVID-19 outbreak. Patients who underwent surgery in the first quarter of 2020 had shorter inpatient stays (3.8 vs. 4.5 days), larger percentage of discharges by postoperative day 5 (86.8 vs. 74.9%), and a larger proportion of patients discharged to their own homes (68 vs. 54%). The overall complication rate (1.3 vs. 3%) and readmission within 30 days (2.6 vs. 2%) was similar between both groups. ERAS protocols appear to reduce hospital lengths of stay for patients undergoing knee arthroplasty without increasing the risk of short-term complications and readmissions. The beneficial effects of ERAS appear to be amplified by and are synchronous with the requirements of operating in the era of a pandemic.

Orthopaedic surgery after COVID-19 - A blueprint for resuming elective surgery after a pandemic.

BACKGROUND: The COVID-19 outbreak was fraught with danger and despair as many medically necessary surgeries were cancelled to preserve precious healthcare resources and mitigate disease transmission. As the rate of infection starts to slow, healthcare facilities and economies attempt to return to normalcy in a graduated manner and the massive pent-up demand for surgeries needs to eventually be addressed in a systematic and equitable manner. MATERIALS AND METHODS: Guidelines from the Alliance of International Organizations of Orthopaedics and Traumatology, Orthopaedic Trauma Association, American College of Surgeons, American Society of Anaesthesiologists, Association of perioperative Registered Nurses, American Hospital Association, Centers for Medicare and Medicaid Services, World Health Organization and Centers for Disease Control and Prevention were evaluated and summarized into a working framework, relevant to orthopaedic surgeons. RESULTS: The guiding principles for restarting elective surgeries in a safe and acceptable manner include up-to-date disease awareness, projection and judicious management of equipment and facilities, effective human resource management, a fair and transparent system to prioritize cases, optimization of peri-operative workflows and continuous data gathering and clinical governance. CONCLUSION: The world was ill prepared for the initial COVID-19 outbreak. However, with effective forward planning, institutions can ramp-up elective surgical caseload in a safe and equitable manner.

Prospective Evaluation of the Time Required for Insertion of 380 Lumbar and Sacral Pedicle Screws Using Navigation with an Intraoperative 3-Dimensional Imaging System.

BACKGROUND: The aim of this study was to evaluate the time required for various parts of the procedure to insert lumbar and sacral pedicle screws using navigation with an intraoperative, 3-dimensional imaging system. Comparison of these timings was carried out for different surgical indications. METHODS: This was a single-surgeon prospective cohort study of 69 consecutive patients (between August 2013 and June 2018) who underwent insertion of 380 pedicle screws into the lumbar and sacral vertebrae. Surgical indications, average time required for surgical exposure and attachment of the reference frame, average time required until completion of the first pedicle screw insertion, and average time required for insertion of a single pedicle screw were evaluated. RESULTS: The average time required from skin incision to reference frame attachment was 28.3 ± 20.4 (mean ± SD) minutes, and the average time required from reference frame attachment to completion of first pedicle screw insertion was 22.3 ± 9.6 minutes. The average time required for insertion of a single pedicle screw was 7.8 ± 2.7 minutes. When surgical indications were compared, the average time required for insertion of a single pedicle screw was 7.7 ± 2.6 minutes in surgery for spondylosis-related stenosis, 8.1 ± 2.8 minutes for degenerative scoliosis, and 8.2 ± 3.6 minutes for metastatic tumor (P = .89). There were no significant changes in these timings over consecutive 6-month periods. CONCLUSIONS: There is no significant learning curve and no significant difference in navigation setup and pedicle screw insertion timings with intraoperative 3-dimensional navigation systems for surgeries of different pathologies and levels of surgery. LEVEL OF EVIDENCE: 2.

A surgeon's role in fighting a medical pandemic: Experiences from the unit at the epicentre of COVID-19 in Singapore - A cohort perspective.

IMPORTANCE: Although Singapore was one of the first countries outside of China to be affected by COVID-19, for the first 2.5 months since its first reported case on January 23, 2020, it remained one of the few nations with successful containment of spread of the pandemic with little mortality and zero intra-hospital transmissions, without instituting a major lockdown of the country. In times of an infectious epidemic where medical subspecialties lead the frontline, a surgeon's role becomes rather vague. However, the only obstacle that stands in between the surgeon and fighting in the frontline of an infectious disease outbreak, is the traditional perception of what a surgeon can do. By presenting the strategies employed by our institution and its surgical unit, which remains the epicenter of the COVID-19 fight in Singapore, together with our medical counterparts, we hope to be able to improve our practices to respond and prevent the pandemic from escalating further as a collective community of surgeons across the globe. OBSERVATIONS: Contingencies should be in place for prioritization of existing patients, triaging and treatment of suspected patients, infection control, manpower management and novel strategies for inter-disciplinary communications and education in a hospital's surgical unit during a pandemic. Working in a high risk environment with manpower and resource limitations for prolonged periods of time has effect on morale and affects surgeon burn-out. Transparent communication, avenues to address psychological needs of surgeons and leadership by example are key strategies in ensuring a sustainable fight against the pandemic. CONCLUSIONS AND RELEVANCE: With the varies strategies implemented, every surgical discipline and every surgeon should be unified and place their desire to operate aside. There should not be any differentiation between surgeon and physician, but instead, everyone has to work together as one united health care front battling the common enemy - COVID-19.

Time-sensitive ambulatory orthopaedic soft-tissue surgery paradigms during the COVID-19 pandemic.

PURPOSE: Timing of surgery for orthopaedic injuries continues to evolve, as an improved understanding of biology, healing, and technological advances continues to challenge historical norms. With the growing COVID-19 pandemic stretching limited healthcare resources, postponing surgery becomes an inevitable and unenviable task for most orthopaedic surgeons, and a shift in outpatient paradigms is required to mitigate poor outcomes in patients. METHODS: A scoping review of five databases on surgical timing and orthopaedic soft-tissue injuries was performed. All randomized controlled trials, longitudinal cohort studies, retrospective case series, systematic reviews, meta-analyses, and expert opinions were included for review, with 65 studies meeting the inclusion criteria. RESULTS: Better outcomes appear to be associated with early surgery for subluxations (< 1 week), recurrent dislocations (> 2 episodes), ligamentous and tendinous injuries (< 2 weeks), and bony avulsion injuries (< 3 weeks). Spinal conditions with neurological compromise should be operated on within 24 hours and spinal instability within 72 hours to reduce the risk of complications and poor outcomes. CONCLUSION: Most soft-tissue orthopaedic injuries can be managed with outpatient ambulatory surgery in a semi-elective setting. As the paradigm for outpatient surgery shifts due to technological advances and the COVID-19 pandemic, it is critical for surgeons to time their surgery appropriately to maintain the high standards of orthopaedic practice.